As a leader in a public hospital, Li Guoqing, during his tenure in charge of the second department of the Second People's Hospital of the city, took advantage of his position to collude with others to defraud medical insurance funds, and also accepted bribes from others multiple times...

Author | Huang Gangqiao, Huang Lei, etc.

Source | China Discipline Inspection and Supervision News

"Even the 'lifesaving money' of the five guarantees households and low-income households is not spared; such hospital cadres should be severely punished!" At the beginning of this year, Li Guoqing, a member of the Party Committee and vice president of the Second People's Hospital of Guangshui City (hereinafter referred to as "the Second Hospital"), was sentenced to 5 years in prison for multiple crimes including embezzlement and dereliction of duty. After the news was released, local residents discussed it widely.

According to investigations, during Li Guoqing's tenure in charge of the Second Outpatient Department of the Second People's Hospital of Guangshui City (hereinafter referred to as "the Second Department"), he colluded with Han Yibin and others to defraud medical insurance funds totaling more than 9 million yuan by means such as issuing "yin-yang prescriptions" and inflating drug costs, personally profiting 216,410 yuan, causing serious losses to the national medical insurance fund.

How did Li Guoqing collude with others to defraud huge medical insurance funds? Why did the relevant departments fail to fulfill their supervisory responsibilities? The matter began with a letter of complaint—

The complaint letter reveals a huge fraud case

"As a leader in a public hospital, Li Guoqing, during his tenure in charge of the second department of the Second People's Hospital, took advantage of his position to collude with others to defraud medical insurance funds, and also accepted bribes from others multiple times..." In July 2018, a real-name complaint letter against Li Guoqing was sent to the Guangshui City Discipline Inspection Commission.

"The content of the complaint letter reflects the strong dissatisfaction of the public. Now, with such strict supervision over the assistance and rescue policies for five guarantees households and low-income households, how dare they still violate the rules? Such behavior that harms the interests of the public must be thoroughly investigated." After receiving the complaint letter, the Guangshui City Discipline Inspection Commission immediately established a special investigation team for verification.

The special investigation team first started from the clues of Li Guoqing's bribery and quickly identified the key witness in the case, Wu. "Wu is one of Li Guoqing's partners in the insurance fraud case and has participated in the fraud multiple times. To prevent witness collusion, after obtaining evidence of Wu's involvement in the fraud, the special investigation team immediately requested the local public security department to assist in the investigation and took coercive measures against him," said a relevant person in the investigation team.

"The implementation of the fraud behavior can be traced back to August 2012 when the higher authorities approved the establishment of the Second Department. The Second Department is nominally a branch, but in reality, it operates independently and is responsible for its own accounting, can set up inpatient beds, treat hospitalized patients, and is supervised by the Second Hospital, with Li Guoqing responsible for daily operations." Wu explained that after Li Guoqing took over the Second Department, he transferred the contracting rights to him and the hospital's suspended doctor Han Yibin. Later, with the launch of the "medical-nursing combination" project, their common interests made them partners.

"When did Li Guoqing start accepting bribes?" "Why did no one notice for six years?" Faced with repeated questioning from investigators, Wu confessed to the facts of him and Han Yibin bribing Li Guoqing. "At the end of October 2015, to profit together, Li Guoqing personally intervened to have the original three shareholders of the Second Department withdraw their shares, allowing me and the original major shareholder Han Yibin to participate in the operation. To show our gratitude, we gave him 15% of the shares and allowed him to participate in the management of the Second Department by receiving a monthly salary of over 10,000 yuan. Li Guoqing is a cautious person; he wouldn't accept direct cash or gifts, so we made him a shareholder for dividends."

Li Guoqing's bribery issue thus came to light. Subsequently, the Guangshui City Discipline Inspection Commission initiated an investigation into Li Guoqing's suspected bribery. As the investigation deepened, the disciplinary and illegal issues of Li Guoqing colluding with Wu and Han Yibin to defraud huge medical insurance funds were gradually exposed.

Five guarantees households actually became "fraud tools"

After Han Yibin and Wu took over the Second Department, they found that the benefits were not good, and making money was not as easy as they thought.

How to find a way to make money? Li Guoqing racked his brains and finally thought of a good idea. One time, Li Guoqing discovered that elderly five guarantees households in a welfare home had great difficulty receiving medical treatment. He suddenly had a "golden idea": why not open the doors of the Second Department to the five guarantees households in the welfare home through the "medical-nursing combination"?

Li Guoqing immediately shared his idea with Han Yibin and Wu, and both agreed wholeheartedly.

With a unified opinion, Li Guoqing began to seek support from the civil affairs department for the "medical-nursing combination" project. "The implementation of the 'medical-nursing combination' can not only enhance the hospital's efficiency but also provide a one-stop medical assistance service for the five guarantees households in the welfare home, which is a win-win situation." Li Guoqing expressed his ideas to the leaders of the city's civil affairs department and quickly received support.

"Medical-nursing combination" refers to the integration of medical resources and elderly care resources to maximize the utilization of social resources. Who would have thought that the "medical-nursing combination" would become a tool for Han Yibin and Wu to amass wealth from the very beginning. "To quickly open the 'medical-nursing combination' channel, Wu arranged for a special car to pick up and drop off the five guarantees households from various welfare homes in Guangshui City for hospitalization, regardless of whether they were sick or not, providing free accommodation and meals," said the case handlers. After the source of patients expanded, Han Yibin was responsible for regularly convening meetings with physician assistants and doctors, instructing physician assistants to issue "yin-yang prescriptions" (issuing real prescriptions for patients and inflated prescriptions for the higher authorities) to defraud medical insurance funds.

To implement the fraud behavior, Han Yibin formulated "four principles" on how to collect hospitalization fees, drug fees, apply for reimbursements, and balance accounts, and insisted on "commanding from the front" at the computer every day. "For patients with low hospitalization costs, immediately require the attending physician to increase drug costs; for patients whose hospitalization costs reach the reimbursement limit, immediately require the attending physician to arrange for the patient to be discharged; for inflated prescriptions, immediately require financial personnel to input them into the computer and apply for reimbursement from the new rural cooperative medical system and medical insurance; for drug inventory showing zero or negative numbers on the pharmacy computer, immediately require physician assistants to inflate the drug quantity and issue false invoices to balance accounts." Han Yibin relied on these "four principles" to fill his own pockets with real money.

In this regard, Li Guoqing, who received benefits, remained indifferent and turned a blind eye.

What Han Yibin and others did not expect was that the "medical-nursing combination" golden idea quickly attracted the attention of private hospitals. At the beginning of 2015, some private hospitals in Guangshui City sensed the "business opportunity" for fraud, treating the elderly five guarantees households in urban welfare homes as "Tang Seng meat," frantically snatching them, with some private hospitals even spending money to attract five guarantees households for hospitalization, leading to a decrease in patients at the Second Department.

Why have the five-guarantee households become the "hot cakes" of hospitals? The reason is simple: when five-guarantee households are hospitalized, they not only enjoy various policies for medical insurance reimbursement but also receive discounts on the general reimbursement ratio, allowing hospitals to recover more medical insurance funds. At the same time, the out-of-pocket expenses for five-guarantee households are reimbursed by the civil affairs department, meaning they do not have to pay a penny, and hospitals can recover funds from multiple channels, which is much more cost-effective than using others to claim insurance. Additionally, helping five-guarantee households can earn hospitals a good reputation, making the use of five-guarantee households for insurance claims more discreet.

In this fierce competition for the medical sources of five-guarantee households, Li Guoqing employed a "flanking tactic." When five-guarantee households in the urban area were lost, he sought them back from the towns. Under Li Guoqing's planning, the second department, in conjunction with the civil affairs department, held a city-wide meeting to promote "medical care integration," which helped the second department fully open the doors to various towns. "By working with the directors of civil affairs offices and village secretaries in various towns, the market for the second department quickly expanded to the doorsteps of scattered five-guarantee elderly households, and in less than two years, the number of hospitalized patients reached 2,899," Li Guoqing said during the investigation.

With the medical sources secured, how to ensure smooth reimbursement of medical insurance funds? Li Guoqing instructed Han Yibin to "open the way with money," successively giving 45,000 yuan in red envelopes to Zhang Zheng'an, the then director of the Guangshui City Medical Insurance Bureau. With Zhang Zheng'an's help, the medical insurance reimbursement funds for the second department always arrived smoothly.

However, the long-term false treatments caused a significant discrepancy between the amount spent on purchasing drugs by the second department and the amount reimbursed for drugs under the new rural cooperative medical insurance. How to evade supervision? Li Guoqing again instructed Han Yibin to find a certain pharmaceutical company to issue false invoices totaling over 600,000 yuan to offset the huge inventory discrepancy of over 2 million yuan caused by long-term false treatments.

The "combined punch" cuts off the behind-the-scenes "black hand".

After grasping a large number of Li Guoqing's disciplinary violations and illegal facts, on May 30, 2018, the Guangshui City Commission for Discipline Inspection and Supervision took legal measures against Li Guoqing.

"I am innocent; I only have disciplinary violations, not illegal crimes. The insurance claims were all done behind my back, and I have nothing to do with it..." At first, when faced with the investigation team's inquiries, Li Guoqing instinctively tried to generalize and cover up the illegal issues.

The case handlers insisted on ideological guidance and gradually moved Li Guoqing. "The discipline inspection cadres patiently did ideological work for me and even specially bought a ventilator for my respiratory disease.Ventilator, with empathy, I will definitely truthfully explain the issues..." Under the influence of the policy and the care of the case handlers, Li Guoqing began to confess his personal disciplinary issues but still tried to hide his criminal behavior.

What broke through Li Guoqing's last ideological defense line was the ironclad evidence before him. During the investigation, the case handlers found that there were three names on the payroll of the second department that were "not genuine." Upon investigation, it was confirmed that these three names were used by Li Guoqing to fraudulently collect salaries. Additionally, there was an unexplained income of 600,000 yuan in the accounts of the second department in November 2015. It was verified that 200,000 yuan of this amount was funds invested in Li Guoqing's name.

Faced with the evidence, Li Guoqing's ideological defense line completely collapsed, and he suddenly realized his regret for his actions. "Initially, I was not interested in the operations of the second department; I just wanted to retire after a few leisurely years there. Later, seeing Han Yibin making some money in the hospital operations, I gradually became excited and wanted to think of some 'golden ideas.' Ultimately, it was my weak awareness of discipline and law that led to a sense of luck and an unlimited expansion of personal desires, which ultimately made me the culprit of the insurance claims fraud," Li Guoqing confessed to the investigators.

"Li Guoqing turned public power into a tool for personal profit. This behavior not only affected the hospital's reputation but also harmed the image of party members and cadres in the eyes of the public, and must be severely punished," said a relevant person in charge of the Guangshui City Commission for Discipline Inspection and Supervision. On August 23, 2018, the Guangshui City Commission for Discipline Inspection and Supervision expelled Li Guoqing from the party and removed him from public office, and his suspected illegal criminal issues were transferred to judicial authorities for legal processing.

In response to the issues exposed by Li Guoqing's case, the Guangshui City Commission for Discipline Inspection and Supervision insisted on promoting reform through cases, promptly issuing supervision suggestions to the unit where the case occurred, requiring the party committee of the unit to hold a special democratic life meeting to conduct a comprehensive self-examination of the problems in implementing the "two responsibilities," and to establish and improve rules and regulations to close regulatory loopholes. At the same time, based on the characteristics of the case, relevant departments jointly carried out a special cleanup of the management and use of medical insurance funds throughout the city, focusing on investigating whether medical insurance institutions engaged in behaviors such as misusing project fees, unreasonable treatments, inducing insured individuals to be hospitalized, fabricating medical services, forging medical documents and receipts, hanging beds for hospitalization, and stealing social security cards. Any disciplinary violations by public officials were promptly investigated and dealt with. After this set of "combined punches," Guangshui City achieved a surplus in medical insurance funds in 2018, saving nearly 100 million yuan compared to previous years.

"In response to the issues exposed by Li Guoqing's case, we organized two teams to carry out self-examination and self-correction work in all private hospitals in the city. A number of problems and irregular funds have been discovered so far. Next, we will continue to urge rectification, promptly close the 'ant holes,' and ensure that the medical insurance fund is not eroded, restoring peace of mind to the public," said a relevant person in charge of the city's Commission for Discipline Inspection and Supervision. (Huang Gangqiao, Huang Lei, Lai Jiawei)

Commentary: Holding high the "sword" of anti-corruption to protect the medical insurance fund.

How to protect the medical insurance fund, which is the "lifesaving money" for the public, requires joint supervision from all levels and departments, especially the discipline inspection and supervision agencies at all levels must adhere to the people-centered concept of supervision and discipline enforcement, insisting on prioritizing strictness, and continuously enhancing the sense of gain for the people.

Insist on supervision without vacancy. Power is the greatest corrosive agent. The medical insurance fund supervision department holds powers such as the review and determination of designated cooperative medical institutions, the allocation of medical reimbursement amounts, the review and payment of medical reimbursements, and daily supervision and inspection. Some leading cadres have been "hunted" by medical institutions, using their positions to facilitate certain medical institutions in increasing medical insurance reimbursement amounts and paving the way for regulatory approvals, making the extraction of medical insurance funds "smooth sailing." The Li Guoqing case exposed issues such as institutional deficiencies and regulatory vacancies in the approval of designated medical institutions for medical insurance. As a discipline inspection and supervision agency, it is necessary to fulfill the responsibility of supervision over supervision, promote the medical insurance fund supervision department to earnestly fulfill its regulatory responsibilities, strengthen daily normative management, and confine power within the cage of the system; to urge the medical insurance department, health and wellness, public security, market supervision, and other departments to jointly carry out special governance actions against insurance fraud, making the operation of medical insurance funds more secure; to effectively utilize big data supervision methods, mobilizing insured individuals to consciously protect the "lifesaving money," and create a good situation of positive interaction, rational checks and balances, orderly participation, and effective supervision throughout society.

Persist in punishing without leniency. To combat hedging and insurance fraud, it is necessary to implement strict punishment with a thunderous momentum and iron-fisted strength. The disciplinary inspection and supervision agencies must thoroughly investigate and strictly punish corruption cases related to medical insurance, focusing on the corruption issues in the medical insurance field. They must resolutely "draw swords" against fraudulent behaviors such as fabricating hospitalizations, hanging beds, forging medical records, excessive medical treatment, collusion inside and outside, and collaborating with others. They should also target the dereliction of duty and negligence of regulatory departments that have led to the misappropriation and fraud of medical insurance funds, seriously investigating and punishing the corrupt individuals and behaviors involved, cutting off the interest chain of medical institutions and medical insurance fund regulatory departments that exploit medical insurance funds, and exerting a deterrent effect.

Persist in education without relaxation. It is necessary to implement an exposure system, insisting on "naming names," and promptly publicly reporting and exposing cases investigated in the medical insurance field, achieving the effect of exposing one case, educating a wide audience, and alerting one party. We must strengthen warning education, solidly carry out work that explains discipline through cases, explains laws through cases, and clarifies responsibilities through cases, urging all levels and departments to analyze, reflect on, and warn against typical corruption issues in the medical insurance field on a case-by-case basis, allowing party members and cadres to be alerted, understand the bottom line, and know the awe, thus building a solid dam against corruption. We should carry out education on integrity in professional conduct, guiding and educating medical insurance fund regulatory personnel, medical institution management personnel, and medical staff to build a solid line of self-discipline, making it impossible for "hunters" to find a breakthrough and for power rent-seeking to find loopholes. (Zheng Jun, the author is a member of the Standing Committee of the Suizhou Municipal Committee of Hubei Province, Secretary of the Municipal Commission for Discipline Inspection, and Director of the Municipal Supervisory Commission)